High-Risk Antepartum Care

• Week 9 focuses on high-risk antepartum care.

Learning Outcomes

• It is important to understand the primary complications of pregnancy, related nursing, and medical care.
• Clinical features related to pregnancy complications should be explained, as well as tests to predict, screen, diagnose, and manage high-risk conditions.
• Potential antenatal complications should be identified for the woman, fetus, and neonate.
• Also important are an understanding of management and interventions of vaginal bleeding in early pregnancy, especially nursing assessments.
• Teach women about antepartum complications.
• Understand pre-existing medical complications of pregnancy and management.

High-Risk Pregnancy

• A high-risk pregnancy results from conditions due to or present before pregnancy which puts both the woman and the fetus at risk.
• Vascular resistance increases during pregnancy.
• Risk factors include hypertension, hyperemesis gravidarum, hemorrhagic conditions, surgery, and urinary tract infections.
• Regular risk assessment throughout the pregnancy and postpartum period is important.

Hemorrhagic Disorders

• Hemorrhagic disorders are medical emergencies.
• Maternal blood loss reduces oxygen-carrying capacity.
• There is an increased risk for hypovolemia, anemia, infection, preterm labor, and preterm birth.
• Oxygen delivery to the fetus is adversely affected.
• Fetal risks include blood loss or anemia, hypoxemia, hypoxia, anoxia, and preterm birth.

Early Pregnancy Bleeding

• Miscarriage (spontaneous abortion) refers to pregnancy loss before 20 weeks, the most common early complication.
• The cause is often unknown and highly variable, possibly related to hormones.
• Interventions should include nursing assessments, monitoring vaginal bleeding, and observation for cramping or contractions.
• Vital signs and pain levels should be assessed.
• Misoprostol and oxytocin can assist.
• Rh(D) immunoglobulin should be given if mother is Rh negative.
• Client understanding and psychological support is also important.

Cervical Insufficiency

• Cervical insufficiency is the premature dilation of the cervix.
• The cervix dilates without uterine contractions, resulting in pregnancy loss.
• The cause is unknown but may be linked to a history of cervical damage or preterm labor.
• Management includes ultrasound to check cervical length.
• Bed rest, avoiding heavy lifting, and progesterone supplementation is required.
• A cervical cerclage can assist.
• Rhogam should be given if Rh negative.
• Close monitoring is needed when preterm labor is indicated.

Bleeding During Early Pregnancy: Ectopic

• Ectopic pregnancy: implantation of the fertilized ovum outside the uterus, commonly one of the fallopian tubes.
• Obstruction or slowing passage of the ovum through the tube can cause an ectopic pregnancy.
• Increased risk is attributed to a history of pelvic inflammatory disease.
• Risk for the woman includes hemorrhage related to rupture and decreased fertility related to removal of the fallopian tube or ovary.
• Assessment includes evaluating for classic clinical signs, like abdominal pain within 7 to 8 weeks after last menses, amenorrhea, and vaginal bleeding; rupture: dull colicky pain, often unilateral, referred shoulder pain, and signs of hemorrhage and shock.
• Management consists of lab/diagnostic testing (transvaginal ultrasound, serum hCG).
• Medical drug therapy (methotrexate) helps dissolve the ovum if is located.
• Surgery (salpingectomy) is required if rupture.
• RhoGam should be given if woman is Rh negative.
• Frequent and thorough nursing actions should include monitoring vital signs as well as continual fluid replacement.
• Maternal psyche should be assessed, along with referral for pregnancy loss support groups.
• Future fertility and contraception should be discussed.

Gestational Trophoblastic Disease (Hydatidiform Mole)

• rapid deterioration of trophoblastic villi in the placenta, there is gestational tissue present, but the pregnancy is not viable
• Two common types (GTD): partial and complete
• Partial: may be fetal tissue, but the embryo does not develop past an early stage and not a viable pregnancy
• Complete: no fetal tissue, no embryo, and no amniotic sac
• Choriocarcinoma: chorionic malignancy
• Assessment includes rapid uterine growth, no fetal heart rate, vaginal bleeding, blood loss, symptoms of preeclampsia before 24 weeks gestation, hCG levels that are persistently elevated or increasing after 10 to 12 weeks
• Diagnosis: ultrasound, high hCG levels
• Management: evacuation of uterine contests (D&C)
• Baseline hCG level, chest x-ray, and pelvic ultrasound
• Serial hCG levels are monitored weekly until they return to normal baseline levels and continued monthly for 12 months.
• Signs of anemia are monitored.
• Chest x-rays are performed every 6 months to detect pulmonary metastasis.
• Reliable contraception is stressed for 1 year.

Late Pregnancy Bleeding: Placenta Previa

• Placenta previa is bleeding during the 2nd and 3rd trimesters.
• It is caused by the placenta implants in the lower uterine segment, near or over the internal cervical os.
• Total/Complete- placenta totally obstructs the internal cervical os.
• Low lying- implantation of placenta in the lower segment of the uterus, close to internal cervical os.
• Factors for:
• Previous placenta previa, uterine scarring.
• Advanced maternal age, smoking.
• Multifetal gestation or close-spaced pregnancies.
• Hypertension/diabetes.
• Painless vaginal bleeding is bright red in the 2nd or 3rd trimester that ceases and then recurs.
• Often happens at 27-32 weeks gestation
• Diagnostic and laboratory tests:
• Placenta placement via transvaginal ultrasound.
• Complete Blood Count (CBC).
• Hemoglobin (Hgb) and Hematocrit (Hct).
• Blood type and Rh status.
• Kleihauer-Betke (KB) test.
• Placenta previa interventions depends on bleeding, location of placenta, gestational age, labor signs, and symptoms.
• Betamethasone (Celestone) is often prescribed.
• Assess maternal vital signs.
• Administer IV fluids and blood products as ordered.
• Expected management includes observation and bedrest.

Abruptio Placentae

• Abruptio placentae is when the placenta separates from the uterine wall prematurely.
• This compromised fetal blood supply.
• It occurs after the 20th week of gestation/ during the 3rd trimester.
• Increased morbidity and morality.
• Risk factors:
  • Advanced maternal age
  • Maternal hypertension
  • Blunt external abdominal trauma (MVA).
  • Cocaine and smoking.
• The assessment includes vaginal bleeding of a dark red consistency, sharp, stabbing pain, and an abdomen that is unusually firm.
• The lab test consists of CBC, fibrinogen levels, clotting studies, type and cross-match.
• Treatment includes rapid assessment and intervention of key indicators.
• Assessment findings:
  • It hurts or is a sharp stabbing pain.
  • Fetal distress or absent FHR.
  • Hypovolemic shock.
• The emergent plan is delivery.
• Tissue perfusion of the body can be aided by turning the client to the left lateral.
• Monitor urinary output and fluid balance.

Late Pregnancy Bleeding

• Late-pregnancy bleeding may arise from cord insertion and placental variations, e.g., velamentous insertion.
• Succenturiate lobe placenta: Cord implants are on the membranes and not on the placenta, risk of baby bleeding disorders increases.

Hypertension in Pregnancy

• Preeclampsia is a factor of complications that takes up 5 to 10% of all pregnancies.
• Hypertensive disorders are complications related to pregnancy.
• Gestational hypertension is new onset and is diagnosed after 20 weeks, and returns to normal 12 weeks postpartum.
• This occurs without previous hypertension and includes BP readings of 140Hg/90 with measurement taken at least 4 times.
• No proteinuria.
• Continuous assessment and regular blood pressure monitoring is crucial.
• A more severe eclampsia with clonus with possible pitting.
• It is only cured with delivery and should be resolved within 48 hours.
• Preexisting conditions is a associated risk and symptoms occur after birth.
• Elevated Elevated BP > or equal to 140/90- 2 measurements at least 4 hours apart.

• /= 3 g protein (1+) or more in 24 hour urine collection.

• Proteinuria will also need to be asses for abnormalities and blood pressures.
• Left lateral position is key.

Preeclampsia Medications

• Magnesium sulfate is needed.
• Antihypertensive.
• Monitor for flushing.
• Look for high protein levels and urine abnormality.
• Watch for fluid tolerance like 100-125/mL/hour
• Elevated Liver enzymes (EL): AST > 70 units/L and ALT elevated > 50 units/L, LDH elevated > 600 units/L
• H: Increased bilirubin (indirect) elevated > 1.2mg/dl
• Monitor magnesium toxicity and signs such reduce DTR and output.
• HELLP is a syndrome that include increased risk and failure.

Chronic and HELLP

• Chronic hypertension is diagnosed before pregnancy and has initial diagnosis and lasts longer than 12 weeks.
• Increased risk of future GDM include type2 diabetes.

Hyperemesis Gravidarum

• Hyperemesis Gravidarum is defined by severe nausea and vomiting beyond 12 week gestation.
• IV hydration will be needed with monitor of and electrolyte with pyridoxine (Vitamin B12).
• Management consist of monitor of lab values.
• Antiemetics slow small frequently feeding.

Multiple Gestation

• Multiple Gestation pregnancy consists of two more more gestations.
• Therapeutic ultrasound is required.

Gestational Diabetes Mellitus (GDM)

• This is a diagnosis of the glucose intolerance during pregnancy.
• The goal is to screen during 24-28 weeks with intrapartum with dextrose solutions.

Summary

• Gestational and Pregestational comprises on mom and baby.
• High risks during pregnancy requires specializing care to optimize fetal outcomes.